MEDICARE: RICK CAVINS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	MO SW 003127	MO

General Provider Information

NPI Number	:	1386722304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICK CAVINS

Provider Business Mailing Address
First Line	:	1000 LAKE SAINT LOUIS BLVD
Second Line	:	SUITE 134
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-1340
Country	:	US
Telephone Number	:	314-616-6699
Fax Number	:	636-561-1665

Provider Business Practice Location Address
First Line	:	1000 LAKE SAINT LOUIS BLVD
Second Line	:	SUITE 134
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-1340
Country	:	US
Telephone Number	:	314-616-6699
Fax Number	:	636-561-1665

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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